KIDZ SUMMER PROGRAM REGISTRATION FORM June 7-16, 2022
CHILDS’ NAME_______________________________________________ AGE______
SCHOOL ATTEND _______________________________ GRADE (in fall) ___________
PHONE (to text to) ______________________________ GENDER: MALE FEMALE
EMAIL _______________________________________________________________
ADDRESS____________________________CITY_________________ZIP_________
PARENT NAME_______________________________ CELL #____________________
(Please list main adult contact for child)
EMERGENCY CONTACTS
NAME/relationship____________________________ CELL # ____________________
NAME/relationship____________________________ CELL # ____________________
NAME/relationship____________________________ CELL # ____________________
WHO WILL PICK UP YOUR CHILD EACH DAY? _________________________________
PICK-UP PERSON CELL PHONE # ___________________________________________
Any Allergies or Medical Conditions we should be aware of? ________________________
Please list any medications your child is currently taking: __________________________
PARENT AGREEMENT : I give my permission for my child to participate in the Huber KIDZ Summer Youth Program. I understand that aspects of the project will be photographed or filmed as a part of the project and may be published online. I will provide/arrange for transportation and will be on time to drop off/pick up my child. I will inform the directors of any absences as far in advance as possible. I will provide a sack lunch including a drink each day for my child, some clothing for costumes (if requested) and agree to pay program fee ($100) or a partial payment and apply for a scholarship* I agree to these guidelines.
Signature: ______________________________________ Date: __________________
* See Chris Feichter for information about Huber Youth Theater Scholarships.